Name *

First Name

Last Name

Phone *

(###)

###

####

Dinner Option *

Prime Filet Mignon Shaken Beef Wok Flame Onions, Spring Salad and Twice Cooked Potatoes

Steamed Ginger Pineapple Sea Bass Line Caught, Scallions, Garlic Soy and Steamed Buk Choy

Veg/Vegan Option Kung Pao Eggplant Garlic Soy and Steamed Buk Choy

I'm only attending the mixer. No dinner option is necessary.

Which event will you be attending? *

If you plan to attend both, please select both options.

6p Cocktail Hour and Mentee/Mentor Mixer

7p Dinner Program

Please select your career level *

Attending Neurosurgeon

Resident

Fellow

Medical Student

Postgraduate Student

Undergraduate Student

Sponsor

Other